The current state of the issue of pressure ulcers: relevant pathophysiological and clinical aspects

Background. Pressure ulcers remain one of the most pressing problems in patients in a prolonged unconscious state, leading to significant medical and social consequences. The prevalence of the condition among hospitalized patients reaches 18%. At the same time, in intensive care unit patients, the risk of developing pressure ulcers rises to 40-60% depending on the duration of immobilization.
Objective. To provide a review of current literature on the pathogenesis, diagnosis, treatment and prevention of pressure ulcers, as well as to examine the morphofunctional features of the skin underlying the development of ischemic necrotic changes and key risk factors. Additionally, it is planned to systematize data on the effectiveness of preventive measures in different clinical groups.
Materials and methods. The study analyzed 55 literature sources from various databases. The influence of mechanical pressure, various physical factors, chemicals, microorganisms, sleep disturbances, stress, systemic diseases and post intensive care syndrome on skin barrier function was studied. Risk factors for pressure ulcer development (reversible – hypotension, hypovolemia, hypoproteinemia; irreversible – age) and their mechanisms of action (impaired microcirculation, trophism and innervation due to vascular obstruction, hypoxia under prolonged pressure – more than 1-2 hours) were considered. To assess data reliability, a meta analysis method was applied to individual studies with a high level of evidence.
Results. Depending on the disease stage, pressure ulcers are treated with hydrocolloid, hydrogel, alginate, gel forming foam dressings, as well as surgical (including removal of necrotic tissue) and physiotherapeutic methods. The prospects for using innovative methods were discussed. It was concluded that timely diagnosis and treatment of pressure ulcers is a multidisciplinary task that remains highly relevant. The implementation of comprehensive preventive programs has reduced the incidence of severe pressure ulcer forms by 22% in the observed patient cohorts.

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline: The International Guideline. 2025. Available at: https://internationalguideline.com/the-international-guideline [accessed 01.06.2025].

2. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Alliance PPPI. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline: The International Guideline. 2019. Available at: https://internationalguideline.com/s/CPG2019edition-digital-Nov2023version.pdf [accessed 01.06.2025].

3. Industry standard. Standardization system in healthcare of the Russian Federation. Patient management protocol. Pressure ulcers (L.89). OST 91500.11.0001-2002. Patient management protocol. Pressure ulcers. Available at: https://docs.cntd.ru/document/1200119472 [accessed 23.05.2026]. (In Russ.)]

4. Order of the Ministry of Health of the Russian Federation dated 17.04.2002 No. 123 "On approval of the industry standard ‘Patient management protocols. Pressure ulcers’". Available at: https://normativ.kontur.ru/document?moduleId=1&documentId=74654 [accessed 23.05.2026]. (In Russ.)

5. National Standard of the Russian Federation. Good medical practice. Infological model. Pressure ulcer prevention. GOST R 56819-2015. Available at: gost-r-56819-2015-prolezhni.pdf [accessed 23.05.2026]. (In Russ.)

6. Shen N. P., Kislyakova V. A., Gritsevich O. S., Kovalev D. V., Novikova T. V. Features of nutritional status and possibilities of clinical nutrition in prevention and treatment of pressure ulcers in ICU patients. Lechaschi Vrach. 2020; 12 (23): 46-54. DOI: 10.26295/OS.2020.73.68.010. (In Russ.)]

7. Nghiem S., Campbell J., Walker R. M., Byrnes J., Chaboyer W. Pressure injuries in Australian public hospitals: A cost of illness study. Int J Nurs Stud. 2022; 130: 104191. DOI: 10.1016/j.ijnurstu.2022.104191. PMID: 35436596.

8. Pasechnik I. N., Novikova T. V. Pressure ulcers: new approaches to treatment. Lechaschi Vrach. 2022; 4 (25): 38-43. DOI: 10.51793/OS.2022.25.4.007. (In Russ.)

9. Kang S., Amagai M., Bruckner A. L., Enk A. H., Margolis D. J., McMichael A. J., Orringer J. S. Fitzpatrick’s Dermatology. 9th ed. New York: McGraw Hill Education, 2019. 2 vols., 4115 p. ISBN: 978 0 07 183779 8.

10. Petrova S. Yu., Al’banova V. I. Skin barrier function and the role of fat soluble vitamins in correcting its disorders. Vestnik dermatologii i venerologii. 2022; 98 (3): 24-33. DOI: https://doi.org/10.25208/vdv1313. (In Russ.)]

11. Fluhr J. W., Akengin A., Bornkessel A., et al. Additive impairment of the barrier function by mechanical irritation, occlusion and sodium lauryl sulphate in vivo. Br J Dermatol. 2005; 153 (1): 125-131. DOI: 10.1111/j.1365 2133.2005.06430.x. PMID: 16029337.

12. Uter W., Gefeller O., Schwanitz H. J. An epidemiological study of the influence of season (cold and dry air) on the occurrence of irritant skin changes of the hands. Br J Dermatol. 1998; 138 (2): 266-272. DOI: 10.1046/j.13652133.1998.02072.x. PMID: 9602872.

13. Uter W., Werfel T., Lepoittevin J. P., White I. R. Contact Allergy – Emerging Allergens and Public Health Impact. Int J Environ Res Public Health. 2020; 17 (7): 2404. DOI: 10.3390/ijerph17072404. PMID: 32244763.

14. Bouten C. V., Oomens C. W., Baaijens F. P., Bader D. L. The etiology of pressure ulcers: skin deep or muscle bound? Arch Phys Med Rehabil. 2003; 84 (4): 616-619. DOI: 10.1053/apmr.2003.50038. PMID: 12690603.

15. Gefen A., Brienza D. M., Cuddigan J., Haesler E., Kottner J. Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. Int Wound J. 2022; 19 (3): 692-704. DOI: 10.1111/iwj.13667. PMID: 34382331.

16. Oomens C. W., Bader D. L., Loerakker S., Baaijens F. Pressure induced deep tissue injury explained. Ann Biomed Eng. 2015; 43 (2): 297-305. DOI: 10.1007/s10439 014 1202 6. PMID: 25480479.

17. Chien W.-C., Tsai T.-F. The Pressurized Skin: A Review on the Pathological Effect of Mechanical Pressure on the Skin from the Cellular Perspective. Int J Mol Sci. 2023; 24 (20): 15207. DOI: 10.3390/ijms242015207. PMID: 37894888.

18. Morgun E. I., Rogovaya O. S., Vorotelyak E. A. Ischemic non healing skin wound model: cell death and wound healing mechanisms. Sovremennye tekhnologii v meditsine. 2018; 10 (4): 69-77. DOI: 10.17691/stm2018.10.4.08. (In Russ.)

19. Knight S. L., Taylor R. P., Polliack A. A., Bader D. L. Establishing predictive indicators for the status of loaded soft tissues. J Appl Physiol (1985). 2001; 90 (6): 2231-2237. DOI: 10.1152/jappl.2001.90.6.2231. PMID: 11356787.

20. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Alliance PPPI. Prevention and Treatment of Pressure Ulcers/ Injuries: Clinical Practice Guideline: The International Guideline. 2019. Available at: https://internationalguideline.com/s/CPG2019edition-digital-Nov2023version.pdf [accessed 01.06.2025].

21. Hoogendoorn I., Reenalda J., Koopman B., Rietman J. S. The effect of pressure and shear on tissue viability of human skin in relation to the development of pressure ulcers: a systematic review. J Tissue Viability. 2017; 26 (3): 157-171. DOI: 10.1016/j.jtv.2017.04.003. PMID: 28457615.

22. Sree V. D., Rausch M. K., Tepole A. B. Linking microvascular collapse to tissue hypoxia in a multiscale model of pressure ulcer initiation. Biomech Model Mechanobiol. 2019; 18 (6): 1947-1964. DOI: 10.1007/s10237 019 01187 5. PMID: 31203488.

23. Kwek M. S. Y., Thangaveloo M., Hui S. L. B., Madden L. E., Phillips A. R., Becker D. L. Characterisation of an ischemia reperfusion model for the formation of a stage I pressure ulcer in mouse skin. J Tissue Viability. 2021; 30 (3): 352-362. DOI: 10.1016/j.jtv.2021.03.004. PMID: 33875344.

24. Loerakker S., Manders E., Strijkers G. J., Nicolay K., Baaijens F. P., Bader D. L., et al. The effects of deformation, ischemia, and reperfusion on the development of muscle damage during prolonged loading. J Appl Physiol (1985). 2011; 111 (4): 1168-1177. DOI: 10.1152/japplphysiol.00389.2011. PMID: 21757578.

25. Bakcek Akcelik O., Ayhan H., Ali Aksoy O., Alp Goksel B., Caliskan E., Ceylan A., et al. Development of a pig model of spontaneous pressure injury: A randomized self controlled study. J Tissue Viability. 2024; 33 (2): 284-291. DOI: 10.1016/j.jtv.2024.01.004. PMID: 38369386.

26. Evora A. S., Abiakam N., Zhang Z., Johnson S. A., Adams M. J., Bader D. L., et al. Characterisation of superficial corneocyte properties over category I pressure ulcers: Insights into topographical and maturation changes. J Dermatol Sci. 2023; 112 (2): 63-70. DOI: 10.1016/j.jdermsci.2023.08.008. PMID: 37953180.

27. Kawasaki S., Nishimura Y., Kamijo Y. I., Uenishi H., Nakamura T., Kouda K., et al. Relationship between ultrasonographically low echoic lesions under the skin, wheelchair sitting time, and interface pressure on ischial region in individuals with chronic spinal cord injury. J Spinal Cord Med. 2021; 44 (6): 978-984. DOI: 10.1080/10790268.2020.1746873. PMID: 32441562.

28. Kottner J., Black J., Call E., Gefen A., Santamaria N. Microclimate: A critical review in the context of pressure ulcer prevention. Clin Biomech (Bristol). 2018; 59: 62-70. DOI: 10.1016/j.clinbiomech.2018.09.010. PMID: 30199821.

29. Arkatova E. A., Letyaeva O. I., Sidorenko O. A. Comparative analysis of species and quantitative composition of facial skin microbiota in healthy women. Klinicheskaya laboratornaya diagnostika. 2024; 69 (12): 700-706. DOI: https:// doi.org/10.51620/0869 2084 2024 69 12 700 706. EDN: DABXPZ. (In Russ.)

30. Sobol’ E. A., Morozov A. M., Zhukov S. V., Minakova Yu. E., Protchenko I. G. Analysis of human skin microbiota. Vestnik novykh meditsinskikh tekhnologii. Elektronnoe izdanie. 2021; 6: Publication 3 3. Available at: http://www.medtsu.tula.ru/VNMT/Bulletin/E2021 6/3 3.pdf [accessed 12.11.2021]. DOI: 10.24412/2075 4094 2021 6 3 3. (In Russ.)

31. Rahim K., Saleha S., Zhu X., Huo L., Basit A., Franco O.L. Bacterial contribution in chronicity of wounds. Microb Ecol. 2017; 73 (3): 710-721. DOI: 10.1007/s00248 016 0867 9. PMID: 27742997.

32. Tisch Mendes J., Klein R. J. The value of a biopsy in chronic ulcers: a case series. Wounds. 2022; 34 (4): 119-123. DOI: https://doi.org/10.25270/wnds/2022.119123. PMID: 35452409.

33. Yarets Yu. I., Slavnikov I. A., Dundarov Z. A. Colonized, critically colonized and infected wounds: differentiation using clinical and microbiological and morphological methods of investigation. Health and Ecology Issues. 2022; 19 (2): 63-75. DOI: https://doi.org/10.51523/27086011.202219208. (In Russ.)

34. Yarets Yu. I. The significance of studying the cytotoxicity of bacterial biofilm to assess the potential ability of the microbiota to prolong the inflammatory phase of the wound process. Laboratory diagnostics. Eastern Europe. 2022; 11 (2): 198-213. DOI: https://doi.org/10.34883/PI.2022.11.2.017. (In Russ.)]

35. Wettstein R., Valido E., Buergin J., et al. Understanding the impact of spinal cord injury on the microbiota of healthy skin and pressure injuries. Sci Rep. 2023; 13 (1): 12540. DOI: 10.1038/s41598 023 39519 2. PMID: 37532801.

36. Khurshid M., Akash M. S. Human Microbiome: Techniques, Strategies, and Therapeutic Potential. 1st ed. Singapore: Springer Nature Singapore, 2024. 712 p. ISBN: 978 981 97 3789 5.

37. De Wert L. A., Rensen S. S., Soons Z., et al. The cutaneous microbiome in hospitalized patients with pressure ulcers. Sci Rep. 2020; 10 (1): 5963. DOI: 10.1038/s41598 020 62918 8. PMID: 32249804.

38. Silver J. R. History of the treatment of spinal injuries. Postgrad Med J. 2005; 81 (952): 108-114. DOI: 10.1136/pgmj.2004.019992. PMID: 15701743. PMCID: PMC1743190.

39. Agrawal K., Chauhan N. Pressure ulcers: Back to the basics. Indian J Plast Surg. 2012 May; 45 (2): 244-254. DOI: 10.4103/0970 0358.101287. PMID: 23162223. PMCID: PMC3495374.

40. Takagi T., Okayama T., Asai J., et al. Topical application of sustained released carbon monoxide promotes cutaneous wound healing in diabetic mice. Biochem Pharmacol. 2022; 199: 115016. DOI: 10.1016/j.bcp.2022.115016. PMID: 35331735.

41. Stinson M., Crawford S., Madden E. Current clinical practice in 24 hour postural management and the impact on carers and service users with severe neurodisability. British Journal of Occupational Therapy. 2021; 84 (6): 355-365. DOI: 10.1177/0308022620944739.

42. Yap T. L., Horn S. D., Sharkey P. D., et al. Effect of varying repositioning frequency on pressure injury prevention in nursing home residents: TEAM UP trial results. Adv Skin Wound Care. 2022; 35 (6): 315-325. DOI: 10.1097/01.asw.0000817840.68588.04. PMID: 35051978.

43. Gillespie B. M., Walker R. M., Latimer S. L., et al. Repositioning for pressure injury prevention in adults. Cochrane Database Syst Rev. 2020; 2020 (6). PMID: 32484259. DOI: 10.1002/14651858.cd009958.pub3.

44. Zhuo X., Pan L., Zeng X. The effects of the 45° semi-recumbent position on the clinical outcomes of mechanically ventilated patients: a systematic review and meta-analysis study. Ann Palliat Med, 2021; 10 (10): 10643-10651. PMID: 34763512. https://doi.org/10.21037/apm-21-2359.

45. Nieto Garcia L., Carpio Perez A., Moreiro Barroso M. T., et al. Can an early mobilisation programme prevent hospital acquired pressure injuries in an intensive care unit? A systematic review and meta-analysis. Int Wound J. 2021; 18 (2): 209-220. DOI: 10.1111/iwj.13516. PMID: 33236855.

46. Citty S. W., Cowan L. J., Wingfield Z., Stechmiller J. Optimizing nutrition care for pressure injuries in hospitalized patients. Adv Wound Care. 2019; 8 (7): 309-322. DOI: 10.1089/wound.2018.0925. PMID: 31832278.

47. McClave S. A., Taylor B. E., Martindale R. G., Warren M. M., Johnson D. R., Braunschweig C., et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016; 40 (2): 159-211. DOI: 10.1177/0148607115621863. PMID: 26773077.

48. Langer G., Wan C. S., Fink A., et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2024; 2: CD003216. DOI: 10.1002/14651858.cd003216.pub3. PMID: 38345088.

49. Clark M., Schols J. M. G. A., Benati G., Jackson P., Engfer M., Langer G., et al. Pressure ulcers and nutrition: A new European guideline. J Wound Care. 2004; 13 (7): 267-272. DOI: 10.12968/jowc.2004.13.7.26634. PMID: 15977767.

50. Hill J. E., Edney S., Hamer O., Williams A., Harris C. Interventions for the treatment and prevention of pressure ulcers [published correction appears in Br J Community Nurs. 2022; 27 (7): 314. Br J Community Nurs. 2022; 27 (Sup6): S28-S36. DOI: 10.12968/bjcn.2022.27.Sup6.S28. PMID: 35671199.

51. Slepnev S. Yu., Baleev M. S., Ryabkov M. G. Experience of surgical treatment of pressure ulcers in patients with traumatic spinal cord disease: efficacy and risk of complications. Zhurnal im. N.V. Sklifosovskogo. Neotlozhnaya meditsinskaya pomoshch’. 2025; 14 (2): 346-354. DOI: https://doi.org/10.23934/222390222025142346354. (In Russ.)]

52. Taeger C. D., Muehle C., Kruppa P., Prantl L., Biermann N. Negative Pressure Wound Therapy – A Vacuum Mediated Positive Pressure Wound Therapy and a Closer Look at the Role of the Laser Doppler. J Clin Med. 2024; 13 (8): 2351. DOI: 10.3390/jcm13082351. PMID: 38673623.

53. Shulutko A. M., Osmanov E. G., Altukhov E. L., Yakovlev A. A., Boblak Yu. A., Gandybina E. G., Gorbacheva A. V., Patalova A. R., Khmyrova S. E., Khusainova N. R. Morphological aspects of pressure ulcer healing under high frequency electrical stimulation in patients with severe brain injury. Rossiiskii meditsinskii zhurnal. 2024; 30 (1): 7-14. DOI: 10.17816/medjrf472099. (In Russ.)

54. Chaudon M. J., Hulea O., Yakoub A., Monnier P., Saadaoui M. Wearable device for iontophoretic treatment and monitoring of pressure ulcers: Proof of concept. Med Eng Phys. 2022; 107: 103861. DOI: 10.1016/j.medengphy.2022.103861. PMID: 36068041.

55. Moore Z. E., Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database Syst Rev. 2018; 12 (12): CD009362. DOI: 10.1002/14651858.CD009362.